Session IX - Pediatrics and Spine

Decompression and Lumbopelvic Fixation for Sacral Fracture-Dislocations with Neurologic Deficits

Carlo Bellabarba, MD¹; Thomas A. Schildhauer, MD²; Sohail K. Mirza, MD¹; Sean E. Nork, MD¹; M.L. Chip Routt, Jr., MD¹; Jens R. Chapman, MD¹;

¹Harborview Medical Center, University of Washington, Seattle, Washington, USA;

²BG-Kliniken Bergmannsheil, Ruhr-Universitat Bochum, Germany

Purpose: Sacral fracture-dislocations with cauda equina deficits are high-energy injuries, the treatment of which is controversial. The effect of early decompression and stabilization is unclear. Neurologic recovery has not been objectively evaluated in past series, putting into question reported recovery rates. Sacral anatomic constraints make standard principles of fracture reduction, neural decompression, and stable fixation difficult to apply. Lumbopelvic fixation allows indirect fracture stabilization by transferring loads directly from the acetabulum to the lumbar spine, thus avoiding the difficulties inherent in achieving sacral fixation. The purpose of this study was to report the results of sacral decompression and lumbopelvic fixation for sacral fracture-dislocations with neurologic deficits by using an objective method for evaluation of neurologic recovery.

Methods: A complete retrospective review was conducted of all medical records, original radiographs, and prospectively collected data of 18 consecutive patients with sacral fracture-dislocations and cauda equina deficits identified between 1997 and 2002 through institutional spine and trauma databases. Fractures were classified according to Denis, Roy-Camille, and Strange-Vognsen. All were treated with open reduction, sacral decompression, and lumbopelvic fixation. Radiographic and clinical results of treatment were evaluated. Neurologic outcome was measured by Gibbons' criteria.

Results: Sacral fractures healed in all 18 patients without loss of reduction. Average sacral kyphosis improved from 41° to 24°. Fifteen patients (83%) had normalization or improvement of bowel and bladder deficits, although only 10 patients (56%) had improved Gibbons scores. Average Gibbons type improved from 4 to 2.8 at the 19-month average follow-up. Rod breakage (33%) and infection (17%) were the most common complications. Recovery of bowel and bladder function was more likely in patients with intact lumbosacral roots (86% vs. 36%, P = 0.066) and incomplete deficits (100% vs. 47%, P = 0.241), although the small cohort size precluded statistical significance.

Conclusions: Lumbopelvic fixation safely and effectively provided the stability necessary for mobilization and weightbearing without loss of reduction in polytraumatized neurologically impaired patients undergoing extensive sacral decompression. Although neurologic improvement was noted in 83% of patients, only 56% of patients had measurable recovery according to objective criteria. However, the functional improvement noted in most patients and the complete recovery of bowel and bladder function in all but one patient with intact sacral roots were encouraging.